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How New Technology Can Help Claims Managers

By AllMed Healthcare Management

Information technology (IT) has long been touted as the key to improved business processes. So, how is IT advancing to help make a claims manager's life easier, better respond to patients' needs, meet mandated guidelines, ensure patient privacy, and bring efficiencies to the overall process?

New advancements, such as electronic data interchange (EDI) systems that help connect insurers to patients and physicians, have already made their mark in the healthcare industry. Nearly every large provider or hospital delivery system has some sort of EDI system in place. Electronic medical record (EMR) systems hold the promise of making patient information accessible to all parties, any time anywhere, yet only seven percent of today's providers have EMR systems in place. And, how do claims managers tie into these systems securely and efficiently?

According to the 1996 Health Insurance Portability and Accountability Act (HIPAA) legislation, all U.S. health care providers and payers must ensure they can send and receive private health information pursuant to HIPAA law by using standard, HIPAA-compliant code sets; HIPAA-compliant transactions; eliminate all proprietary and/or local codes for waived services, and accommodate unique identifiers for providers, health plans (payers) and employers. Once the HIPAA EDI standard is fully in place, it will help reduce management overhead and costs.

The next wave of technology advancements may lie directly on the Internet. Internet-based Web portals hold the promise of helping claims managers improve the overall claims review process by enabling them to collaborate with their customers and vendors electronically. This includes requesting and receiving independent medical reviews, with HIPAA-compliant transmission of medical records and other sensitive PHI.

As new forms of electronic data exchange emerge, claims managers can look forward to a new era with improved turn around times; more manageable, lower costs; increased security, and improved HIPAA compliance.

About The Author

AllMed Healthcare Management Founded in 1995, AllMed (, is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers.


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